The nurse will be using the Braden Scale with each admit to the longterm care center. Which of these will be utilized in a Braden Scale assessment? (Select all that apply.)

Choice A reason: Inflammatory is the phase of wound healing that occurs at the time of injury and lasts about 35 days, because it is the first and immediate response to tissue damage. Inflammatory is the phase of wound healing that involves the activation of the immune system, the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of a clot. Inflammatory is the phase of wound healing that aims to control bleeding, prevent infection, and prepare the wound for healing.

Choice B reason: Proliferative is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the inflammatory phase and lasts about 23 weeks. Proliferative is the phase of wound healing that involves the growth and multiplication of new cells, the formation of granulation tissue, the synthesis of collagen, the contraction of the wound edges, and the development of epithelial tissue. Proliferative is the phase of wound healing that aims to fill the wound, restore the strength, and cover the defect.

Choice C reason: Maturation is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the proliferative phase and lasts about several months to years. Maturation is the phase of wound healing that involves the remodeling and reorganization of the collagen fibers, the reduction of scar tissue, the improvement of elasticity, and the restoration of function. Maturation is the phase of wound healing that aims to refine the wound, enhance the quality, and optimize the outcome.

Choice D reason: Intentional is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather a classification of wound healing that depends on the type and extent of tissue damage, the degree of contamination, and the method of closure. Intentional is a classification of wound healing that refers to wounds that are surgically created, have minimal tissue loss, are clean and sterile, and are closed by primary intention, which means that the wound edges are approximated with sutures, staples, or glue. Intentional is a classification of wound healing that results in faster healing, less scarring, and lower risk of infection.

Choice A reason: Inflammation is not an example of a client's primary defense to infection. Inflammation is a secondary defense to infection, which is activated after the primary defense has been breached. Inflammation is a complex process that involves the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of exudate. Inflammation aims to contain, neutralize, and eliminate the infectious agent and to repair the damaged tissue.

Choice B reason: Fever is not an example of a client's primary defense to infection. Fever is a secondary defense to infection, which is activated after the primary defense has been breached. Fever is an elevation of the body temperature above the normal range, which is usually 36.5 to 37.5 degrees Celsius or 97.7 to 99.5 degrees Fahrenheit. Fever is a systemic response to infection that is regulated by the hypothalamus, which is the part of the brain that controls the body's thermostat. Fever enhances the immune system's activity and inhibits the growth of some pathogens.

Choice C reason: Phagocytosis is not an example of a client's primary defense to infection. Phagocytosis is a secondary defense to infection, which is activated after the primary defense has been breached. Phagocytosis is a process that involves the engulfment and destruction of foreign particles, such as bacteria, by specialized cells, such as macrophages and neutrophils. Phagocytosis is a type of cellular immunity that eliminates the infectious agent and prevents its spread.

Choice D reason: Intact skin is an example of a client's primary defense to infection. Intact skin is the first and most important line of defense against infection, as it forms a physical barrier that prevents the entry of pathogens into the body. Intact skin also has chemical and biological properties that resist infection, such as the acidic pH, the secretion of sebum and sweat, and the presence of normal flora. Intact skin protects the underlying tissues and organs from infection and injury.